Specialist sarcoma centres in Australia and New Zealand – addressing equity of access and ensuring best practice through centralization

Centralization of cancer services within Australia remains controversial and challenging, within a number of domains, including the management of bone and soft tissue sarcoma of the extremities, abdomen and retroperitoneum. In this issue of the Journal, the Australia and New Zealand Sarcoma Association (ANZSA) Working Group led by Gyorki and Hong present a summary of recently published guidelines, including the role of specialist centres in the management of sarcoma.¹ Following systematic review, the ANZSA guidelines recommend that both radiotherapy and surgery occur within specialized sarcoma centres.

The development and publication of the ANZSA guidelines, coincided with the release of an Australian Senate inquiry into rare and less common cancers. This inquiry concluded that patients with rare cancers do not receive the same level of support, or have access to the same diagnostic and treatment options, as those with more common cancers.² Sarcoma undoubtedly represents a rare malignancy (1.5% of all new cancer diagnoses) for which the argument for centralization of management is obvious. Standardizing treatment strategies for patients with sarcoma is made all the more challenging by the heterogenous nature of the disease, which comprises over 120 subtypes. As these diverse tumours are better understood on a molecular level, individual patients require a tailored, histology-specific treatment approach developed by an experienced multi-disciplinary team, as well as access to complex surgery, novel systemic treatments and clinical trials. Such tailored treatment can only be achieved consistently at centres with the necessary experience and expertise.

One of the challenges in recommending treatment at a specialist sarcoma centre, is in defining a specialist centre. ANZSA defines specialist sarcoma centres as those which have a tumour-specific multidisciplinary team (MDT) meetings, and actively participate in clinical trials. An issue is to what extent this is standardized or ratified, where ANZSA is not a regulatory body, and centres would seem to be able to self-determine their status somewhat. This compares to Europe, where the European Reference Network (EUROCAN), is not only far more prescriptive in setting out specific standards for MDTs, but establishes recommended thresholds with 100 new patients managed per year, against which centres can be benchmarked.³

While volume-based assessment has always been a controversial metric in surgery, the findings of the systematic review regarding surgery at specialized sarcoma centres conducted by the ANZSA working group would support that morbidity, local recurrence and overall recurrence are all improved where sarcoma surgery, including pre-operative work-up, occurs at a specialized centre.⁴ The literature in retroperitoneal and extremity sarcoma sets the relatively low threshold of 10 cases per year as a definition of high-volume centres.^5-7 It would seem intuitive in countries with smaller populations such as Australia and New Zealand, that intrinsically low-volumes of highly complex and high cost surgery with accompanying allied health and medical management, that funding should be directed to a small-number of well-resourced, highly specialized centres offering best practice management.

Another challenge in recommending treatment at specialized sarcoma centres relates to equity of access, particularly given geography and socioeconomic disparity. This issue may be more relevant in Australia, being a vastly larger country than those in the UK and Europe where centralization of sarcoma services is common. Recent data from a high volume, Australian pelvic exenteration unit would suggest that comparable outcomes can be achieved after highly complex surgery in selected patients from regional and remote areas as in those from metropolitan areas.⁸ A concerning issue is the unknown number of patients who may never be referred for assessment, and who may undergo inadequate upfront surgery, or are deemed unresectable at a local level and different treatment modalities or supportive care are instituted.

Formalizing sarcoma services by clearly defining and accrediting specialist centres and establishing structured referral pathways to these centres may improve access for all Australians with sarcoma, and reduce unwarranted variations in management and outcomes. Such centres require the capability to provide the necessary multidisciplinary assessment (including virtually where appropriate) and treatment, including complex surgery as well as neoadjuvant and adjuvant medical and radiation oncology treatments, including clinical trials. Importantly, such centres must be appropriately resourced to support these referrals with nursing, allied health and research staff. One way of bridging the referral gap is via virtual, or hybrid, multidisciplinary team (MDT) meetings. Virtual MDTs are commonplace at many tertiary centres across multiple tumour streams, and have been proven to be acceptable and feasible within the field of sarcoma.⁹ Patients can have radiology and pathology review and discussion remotely, a tailored management plan can be developed and the patient is required to come to a specialist centre for the minimal time possible.

We would further propose the formation of a collaborative sarcoma network across Australia and New Zealand, to formally recognise and link specialist centres and foster clinical, academic and governance collaboration in a binational network. This will require stakeholder engagement with clinicians, governments both state and federal, professional groups such as ANZSA, and of course patients. If we are to treat all our sarcoma patients in a consistently world class fashion, in accordance with guidelines, it is time to move to formalized centres of excellence for sarcoma in Australia.